Prior Authorization List

00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum (including MAC) 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum (including MAC) 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq. cm or less (when specified for nipple/areola reconstruction) 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation 11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation 11950 Injection of collagen or other filling material 11951 Injection of collagen or other filling material 11952 Injection of collagen or other filling material 11954 Injection of collagen or other filling material 15775 Hair transplant (hairplasty), punch graft, 1 to 15 punch grafts 15776 Hair transplant (hairplasty), punch graft, more than 15 punch grafts 15780 Facial dermabrasion or acid peel/scar revision (of any kind) 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site (eg. tattoo removal) 15786 Abrasion; single lesion (eg. keratosis, scar) 15787 Abrasion, each additional four lesions or less 15788 Chemical peel, facial; epidermal 15792 Chemical peel, non-facial; epidermal 15793 Chemical peel, non-facial; dermal Rev 12/30/15 Page 1 of 50

15819 Cervicoplasty 15820 Blepharoplasty - lower eyelid 15821 Blepharoplasty - lower eyelid with extensive herniated fat pad 15822 Blepharoplasty - upper eyelid 15823 Blepharoplasty - upper eyelid; with excessive skin weighing down lid 15824 Rhytidectomy - brow or face lift 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 Rhytidectomy; glabellar frown lines 15828 Malar (cheek) implants 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 15832 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh 15833 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 15834 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip 15835 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock 15836 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm 15837 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand 15838 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad 15839 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy), other area 15840 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) 15841 Graft for facial nerve paralysis; free muscle graft (including obtaining graft) Rev 12/30/15 Page 2 of 50

15842 Graft for facial nerve paralysis; free muscle flap by microsurgical technique 15845 Graft for facial nerve paralysis; regional muscle transfer 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) 15876 Lipectomy/Liposuction procedures - Suction assisted lipectomy; head and neck 15877 Lipectomy/Liposuction procedures - Suction assisted lipectomy; trunk 15878 Lipectomy/Liposuction procedures - Suction assisted lipectomy; upper extremity 15879 Lipectomy/Liposuction procedures - Suction assisted lipectomy; lower extremity 17106 Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser 17107 Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser 17108 Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser 17380 Electrolysis epilation 19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma 19300 Gynecomastia repair 19316 Mastopexy 19318 Breast Reduction (mammoplasty) 19324 Augmentation of breast - mammoplasty 19325 Augmentation of breast - mammoplasty 19328 Removal of breast implant/material (periprosthetic capsulectomy 19330 Removal of breast implant/material (periprosthetic capsulectomy 19340 Breast procedure - Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 Breast procedure - Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Rev 12/30/15 Page 3 of 50

19350 Breast procedure - Nipple/areola reconstruction 19355 Breast procedure - Correction of inverted nipples 19357 Breast procedure - Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19361 Breast procedure - Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant 19364 Breast procedure - Breast reconstruction with free flap 19366 Breast procedure - Breast reconstruction with other technique 19367 Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site 19368 Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) 19369 Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of site 19380 Breast procedure - Revision of reconstructed breast 19396 Breast procedure - Preparation of moulage for custom breast implant 20605 Temporomandibular Disorders: Arthodesis, aspiration and/or injection; intermediate joint or bursa 20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only 20931 Allograft, morselized, or placement of osteopromotive material, for spine surgery only. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 20936 Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or Rev 12/30/15 Page 4 of 50

thoracic spinal surgeries related to this procedure code. 20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 20974 Bone Growth Stimulator - electrical stimulation to aid bone healing 20975 Bone Growth Stimulator low intensity ultrasound stimulation to aid bone healing 20979 Bone Growth Stimulators - Low intensity ultrasound stimulation to aid bone healing, noninvasive (non-operative) 20982 Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance 20985 Computer-assisted surgical navigational procedure 21010 Temporomandibular Disorders: Arthrotomy, temporomandibular joint 21050 Temporomandibular Disorders: Condylectomy, temporomandibular joint (separate procedure) 21060 Temporomandibular Disorders: Meniscectomy, partial or complete, temporomandibular joint (separate procedure) 21073 Temporomandibular Disorders: Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care) 21083 Nasal (dorsal-external) implants 21087 Nasal (dorsal-external) implants 21116 Temporomandibular Disorders: Injection procedure for temporomandibular joint arthrography 21120 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty 21121 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty Rev 12/30/15 Page 5 of 50

21122 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty 21123 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty 21125 Mandibular/Maxillary (Orthognathic) Surgery - Augmentation, mandibular body or angle; prosthetic material 21127 Mandibular/Maxillary (Orthognathic) Surgery - Augmentation, lower jaw bone 21137 Forehead Reduction 21138 Forehead Reduction 21139 Forehead Reduction 21141 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21142 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21143 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21145 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21146 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21147 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21150 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort II) 21151 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort II) 21154 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort III) 21155 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort III) 21159 Mandibular Osteotomies, Reconstruction Midface (LeFort) 21160 Mandibular Osteotomies, Reconstruction Midface (LeFort) 21172 Mandibular Osteotomies, Reconstruction superior-lateral orbital rim and lower forehead 21175 Mandibular Osteotomies, Reconstruction bifrontal, superior-lateral orbital rims and lower forehead Rev 12/30/15 Page 6 of 50

21179 Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims 21180 Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims 21188 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (other than LeFort type) 21193 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft 21194 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; with bone graft 21195 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation 21196 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation 21198 Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy, mandible, segmental 21199 Mandibular Osteotomies, segmental with genioglossus advancement 21206 Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) 21208 Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty, facial bones; reduction 21210 Mandibular/Maxillary (Orthognathic) Surgery - Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 21215 Mandibular/Maxillary (Orthognathic) Surgery - Graft, bone; mandible (includes obtaining graft) 21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) 21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) 21240 Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) 21242 Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with allograft Rev 12/30/15 Page 7 of 50

21243 Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with prosthetic joint replacement 21244 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible extraoral, with transosteal bone plate (eg, mandibular staple bone plate) 21245 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible or maxilla, subperiosteal implant 21246 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction mandible or maxilla, subperiosteal implant; complete 21247 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts)(e.g., for hemifacial microsomia) 21248 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible or maxilla, endosteal implant 21249 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible or maxilla, endosteal implant 21255 Reconstruction zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) 21256 Mandibular Osteotomies, Reconstruction of orbit (includes obtaining autografts) 21270 Malar (cheek) implants 21685 Hyoid myotomy and suspension 21740 Reconstructive repair of pectus excavatum or carinatum; open 21742 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy 21743 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy 22214 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar 22216 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment 22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar 22505 Manipulation of spine under anesthesia 22510 Kyphoplasty - Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic Rev 12/30/15 Page 8 of 50

22511 Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar 22512 Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar body 22513 Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 22514 Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 22515 Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body 22533 Spinal fusion - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22534 Spinal fusion - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment 22558 Spinal fusion - Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace 22612 Spinal fusion - Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment 22630 Spinal fusion - Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Rev 12/30/15 Page 9 of 50

22632 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar 22634 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure) 22830 Exploration of spinal fusion 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22841 Internal spinal fixation by wiring of spinous processes. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22842 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22843 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22844 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22845 Anterior instrumentation; 2 to 3 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. Rev 12/30/15 Page 10 of 50

22846 Anterior instrumentation; 4 to 7 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22847 Anterior instrumentation; 8 or more vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22849 Reinsertion of spinal fixation device 22851 Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 22852 Removal of posterior segmental instrumentation 22855 Removal of anterior instrumentation 22856 Artificial Intervertebral Discs - total disc arthroplasty, anterior approach, including diskectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar 22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical 22862 Artificial Intervertebral Discs - revision including replacement of total disc arthroplasty, lumbar, single interspace 22865 Artificial Intervertebral Discs - removal of total disc arthroplasty, anterior approach, lumbar, single interspace 22899 Kyphoplasty - unlisted procedure; spine 22999 Unlisted procedure, abdomen, musculoskeletal system 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device Note: Prior authorization for this code will be required effective 5/1/16 Rev 12/30/15 Page 11 of 50

27280 Arthrodesis, sacroiliac joint (including obtaining graft) 27412 Autologous chondroctye transplantation - knee 27415 Autologous/Osteochondral allograft, knee, open 27416 Osteochondral autograft(s), knee, open 27702 Ankle Replacement 28446 Open osteochondral autograft-talus 28890 Extracorpeal shock wave therapy (Orthotripsy)/Orthotripsy (heel) Ossatron 28899 Subtalar Arthroereisis - Unlisted procedure, foot or toes (Orthotripsy) 29800 Temporomandibular Disorders: Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy 29804 Temporomandibular Disorders: Arthroscopy, temporomandibular joint, surgical 29866 Autologous chondrocyte transplantation/arthroscopy knee, surgical; osteochondral autograft(s) (eg. Mosaicplasty) (includes harvesting of the autograft) 29867 Autologous chondrocyte transplantation/arthroscopy knee, surgical; osteochondral autograft(s) (eg. Mosaicplasty) 29868 Meniscal Transplantation 29892 Ankle arthroscopy/surgery 29999 Electrothermal capsular shrinkage (i.e. thermal capsulorrhaphy, electrothermal capsulorrhaphy, thermal capsular shrinkage, electrothermal arthroscopy) as a technique for use in arthroscopic or open surgery for tightening the capsular or ligamentous structures of ankles, hips, knees, or wrists. 30110 Excision, nasal polyp(s), simple 30115 Excision, nasal polyp(s), extensive 30120 Rosacea treatment - excision or surgical planing of skin of nose for rhinophyma 30130 Excision inferior turbinate, partial or complete, any method - Note: Authorization is required only when the diagnosis is Rev 12/30/15 Page 12 of 50

associated with obstructive sleep apnea or snoring 30140 Submucous resection inferior turbinate, partial or complete, any method - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring 30400 Rhinoplasty 30410 Rhinoplasty 30420 Rhinoplasty 30430 Rhinoplasty 30435 Rhinoplasty 30450 Rhinoplasty 30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 30620 Septal or other intranasal dermatoplasty (does not include obtaining graft) 30801 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring 30802 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (i.e., submucosal) - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring 31200 Ethmoidectomy; intranasal, anterior - Note: Authorization is required only when the diagnosis is associated with chronic headaches 31201 Ethmoidectomy; intranasal, total - Note: Authorization is required only when the diagnosis is associated with chronic headaches 31205 Ethmoidectomy, extranasal, total - Note: Authorization is required only when the diagnosis is associated with chronic headaches 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement Rev 12/30/15 Page 13 of 50

31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) 32491 Removal of lung, other than pneumonectomy; with resection-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed 32664 Thorascopy, surgical: with thoracic sympathectomy 32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral 33202 Insertion of epicardial electrode(s); open incision (e.g., thoracotomy, median sternotomy, subxiphoid approach) 33203 Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy) 33207 Cardiac Resynchronization Therapy - Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular 33208 Cardiac Resynchronization Therapy - Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular 33211 Cardiac Resynchronization Therapy - Insertion or replacement of temporary transvenous dual chamber pacing electrodes 33213 Cardiac Resynchronization Therapy -Insertion or replacement of pacemaker pulse generator only; dual chamber Rev 12/30/15 Page 14 of 50

33214 Cardiac Resynchronization Therapy - Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber 33216 Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator 33217 Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator 33224 Cardiac Resynchronization Therapy - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing; with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator 33225 Cardiac Resynchronization Therapy - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter defibrillator or pacemaker pulse generator 33226 Cardiac Resynchronization Therapy - Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator) 33240 Cardiac Resynchronization Therapy - Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator 33249 Cardiac Resynchronization Therapy - Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator 33254 Maze Procedure - Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) 33255 Maze Procedure - Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass 33256 Maze Procedure - Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass 33257 Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary procedure) 33258 Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure) 33259 Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure) Rev 12/30/15 Page 15 of 50

33265 Maze Procedure - Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass 33266 Maze Procedure - Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass 33270 Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed 33271 Insertion of subcutaneous implantable defibrillator electrode 33548 Surgical ventricular restoration procedure, includes prosthetic patch, when performed (e.g., ventricular remodeling, SVR, SAVER, DOR procedures) 35475 Carotid, Vertebral and Intracranial Artery Angioplasty - Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel 36260 Implantable Infusion Pumps - Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver) 36468 Sclerotherapy 36469 Sclerotherapy 36470 Sclerotherapy 36471 Sclerotherapy 36475 Radiofrequency ablation of varicose veins 36476 Radiofrequency ablation of varicose veins 36478 Radiofrequency ablation of varicose veins 36479 Radiofrequency ablation of varicose veins 36511 Therapeutic apheresis; for white blood cells Rev 12/30/15 Page 16 of 50

36512 Therapeutic apheresis; for red blood cells 36513 Therapeutic apheresis; for platelets 36514 Therapeutic apheresis; for plasma pheresis 36515 Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion 36516 Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion 36563 Implantable Infusion Pumps - Insertion of tunneled centrally inserted central venous access device with subcutaneous pump 37215 Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of stent, cervical cartoid artery with distal embolic protection 37216 Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of stent, cervical cartoid artery without distal embolic protection 37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction 37244 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation 41512 Tongue base suspension, permanent suture technique 41530 Tongue - Submucosal ablation of the tongue base, radiofrequency, one or more sites per session 41870 Periodontal Mucosal Grafting 42145 Palatopharynoplasty - UPPP, LAUP's, and somnoplasty 42299 Somnoplasty for snoring 42820 Tonsillectomy and adenoidectomy - review is required only for children under the age of 18 42821 Tonsillectomy and adenoidectomy - review is required only for children under the age of 18 42825 Tonsillectomy, primary or secondary - review is required only for children under the age of 18 42826 Tonsillectomy, primary or secondary - review is required only for children under the age of 18 Rev 12/30/15 Page 17 of 50

43192 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/16 43201 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/16 43210 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/16 43228 Ablative Techniques as a Treatment for Barrett's Esophagus - Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique [when specified as radiofrequency ablation] 43236 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/16 43257 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/16 43258 Ablative Techniques as a Treatment for Barrett's Esophagus - Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s) or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique [when specified as radiofrequency ablation] 43499 Stretta or Endocinch procedure, Endoscopic treatment of GERD 43632 Gastrectomy, partial distal; with gastrojejunostomy 43644 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43645 Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult 43647 Gastric Pacemaker 43648 Gastric Pacemaker 43659 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43770 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43771 Gastric Bypass - revision of adjustable gastric restrictive device component only. Rev 12/30/15 Page 18 of 50

43772 Gastric Bypass - removal of adjustable gastric restrictive device component only. 43773 Gastric Bypass - removal and replacement of adjustable gastric restrictive device component only. 43774 Gastric Bypass - removal of adjustable gastric restrictive device and subcutaneous port components. 43775 Gastric restrictive procedure - Laparoscopy, surgical; longitudinal gastrectomy (i.e., sleeve gastrectomy) 43842 Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult 43843 Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult 43845 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43846 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43847 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43848 Gastric Bypass - revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure). 43881 Gastric Pacemaker 43882 Gastric Pacemaker 43886 Gastric restrictive procedure open; revision of subcutaneous port component only 43887 Gastric restrictive procedure open; removal of subcutaneous port component only 43888 Gastric restrictive procedure open; removal and replacement of subcutaneous port component only 46505 Chemodenervation of internal anal sphincter 47370 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency 47371 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical 47380 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, open, of 1 or more liver tumor(s); radiofrequency Rev 12/30/15 Page 19 of 50

47381 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, open, of 1 or more liver tumor(s); cryosurgical 47382 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency 50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed 50542 Ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed - Laparoscopy, surgical 50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency 50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy 52441 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant 52442 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant 52647 Laser surgery of prostate 52648 Contact laser vaporization of prostate 52649 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation 53850 Transurethral destruction of prostate tissue; by microwave thermotherapy 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy 54125 Gender Reassignment Surgery - Amputation of penis; complete 54360 Penis plastic surgery 54400 Penile Prosthesis Implantation - Insertion of penile prosthesis; non-inflatable (semi-rigid) 54401 Penile Prosthesis Implantation - Insertion of penile prosthesis; inflatable (self-contained) 54405 Penile Prosthesis Implantation - Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Rev 12/30/15 Page 20 of 50

54410 Penile Prosthesis Implantation - Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session 54411 Penile Prosthesis Implantation - Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue 54416 Penile Prosthesis Implantation - Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session 54417 Penile Prosthesis Implantation - Removal and replacement of a non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue 54440 Plastic operation on penis for injury 54520 Gender Reassignment Surgery - Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach 54660 Gender Reassignment Surgery - Insertion of testicular prosthesis 54690 Gender Reassignment Surgery - Laparoscopy, surgical; orchiectomy 55180 Gender Reassignment Surgery - Scrotoplasty; complicated 55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) 55970 Gender Reassignment Surgery - Intersex surgery; male to female 55980 Gender Reassignment Surgery - Intersex surgery; female to male 56625 Gender Reassignment Surgery - Vulvectomy, simple; complete 56800 Gender Reassignment Surgery - Plastic repair of introitus 56805 Gender Reassignment Surgery - Clitoroplasty for intersex state 56810 Perineoplasty, repair of perineum, nonobstetrical (separate procedure) 57110 Gender Reassignment Surgery - Vaginectomy, complete removal of vaginal wall 57291 Gender Reassignment Surgery - Construction of artificial vagina; without graft 57292 Gender Reassignment Surgery - Construction of artificial vagina; with graft Rev 12/30/15 Page 21 of 50

57295 Gender Reassignment Surgery - Revision (including removal) of prosthetic vaginal graft; vaginal approach 57296 Gender Reassignment Surgery - Revision (including removal) of prosthetic vaginal graft; open abdominal approach 57335 Vaginoplasty for intersex state 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) 58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) 58180 Supracervical Abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) 58200 Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node biopsy(s) 58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymphadenectomy 58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy 58260 Vaginal hysterectomy 58262 Vaginal hysterectomy; with removal of tube(s), and or ovary(s) 58263 Vaginal hysterectomy; with removal of tube(s), and or ovary(s) with repair of enterocele 58267 Vaginal hysterectomy, for uterus 250 grams or less; with colpo- urethrocystopexy 58270 Vaginal hysterectomy, with or without removal of tubes(s), with or without removal of ovary(s) with repair of enterocele 58275 Vaginal hysterectomy with total or partial colpectomy 58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele 58285 Vaginal hysterectomy, radical (Schauta type operation) 58290 Vaginal hysterectomy, for uterus greater than 250 grams: 58291 Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovaries 58292 Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovaries Rev 12/30/15 Page 22 of 50

58293 Vaginal hysterectomy, for uterus greater than 250 grams; with colpo-urethrocystopexy 58294 Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele 58541 Laparoscopy, surgical, supracervical hystgerectomy, for uterus 250 grams or less 58542 Laparoscopy, surgical, supracervical hystgerectomy, for uterus 250 grams or less; with removal of tubes(s) and/or ovary(s) 58543 Laparoscopy, surgical, supracervical hystgerectomy, for uterus greater than 250 grams 58544 Laparoscopy, surgical, supracervical hystgerectomy, for uterus greater than 250 grams; with removal of tubes(s) and/or ovary(s) 58548 Laparoscopy surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and/or ovary(s) 58550 Laparoscopy, surgical with vaginal hysterectomy with or without removal of tube(s) and/or ovary(s) (laparoscopic assisted vaginal hysterectomy) 58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s) 58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams 58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s) 58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less 58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less, with removal of tube(s) and/or ovary(s) 58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 grams 58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250, with removal of tube(s) and/or ovary(s) 58953 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection 58954 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection 58956 Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) 58578 HALT procedure (Unlisted laparoscopy procedure, uterus) Rev 12/30/15 Page 23 of 50

61215 Implantable Infusion Pumps - Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter 61630 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous 61635 Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of intravascular stent(s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed 61640 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel 61641 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular family (list separately in addition to code for primary procedure) 61642 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family (list separately in addition to code for primary procedure) 61796 Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; 1 simple cranial lesion 61797 Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; each additional cranial lesion, simple 61798 Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; 1 complex cranial lesion 61799 Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; each additional cranial lesion, complex 61800 Stereotactic Radiosurgery - Application of stereotactic head frame 61863 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperat 61864 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array 61867 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with Rev 12/30/15 Page 24 of 50

use of intraoperative microelectrode recording; first array 61868 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array 61870 Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical 61875 Craniectomy for implantation of neurostimulator electrodes, cerebellar; subcortical 61885 Deep Brain Stimulation - Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 61886 Deep Brain Stimulation - Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays 62263 Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 2 or more days 62264 Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 1 day 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar 62350 Implantable Infusion Pumps - Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62351 Implantable Infusion Pumps - Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62360 Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump 62362 Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Rev 12/30/15 Page 25 of 50

63005 Spinal surgery - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis 63011 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; sacral 63012 Spinal surgery - Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 63017 Spinal surgery - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar 63030 Spinal surgery - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar 63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, lumbar. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 63042 Spinal surgery - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar 63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 63047 Spinal surgery - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. Rev 12/30/15 Page 26 of 50

63056 Spinal surgery - Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) 63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. 63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment 63082 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) 63085 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment 63087 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment 63090 Vertebral corpectomy (vertebral body resection), partial or complete; transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment 63091 Vertebral corpectomy (vertebral body resection), partial or complete; transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment 63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar 63620 Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; 1 spinal lesion 63621 Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; each additional spinal lesion 63650 Neurostimulator Implantation - Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63685 Neurostimulator Implantation - Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive Rev 12/30/15 Page 27 of 50

coupling 64553 Neurostimulator Implantation - Percutaneous implantation of neurostimulator electrodes; cranial nerve 64555 Neurostimulator Implantation - Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) 64595 Gastric Pacemaker 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve 64633 Destruction by neurolytic agent paravertebral facet joint nerve; lumbar or sacral, single level 64634 Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level [when specified as radiofrequency facet neurolysis] 64635 Destruction by neurolytic agent; cervical or thoracic, single level 64636 Destruction by neurolytic agent; cervical or thoracic, each additional level 64640 Destruction by neurolytic agent; other peripheral nerve or branch 64716 Neuroplasty and/or transposition; cranial nerve 64732 Transection or avulsion of; supraorbital nerve 64734 Transection or avulsion of; infraorbital nerve 64736 Transection or avulsion of; mental nerve 64738 Transection or avulsion of; inferior alveolar nerve by osteotomy 64740 Transection or avulsion of; lingual nerve 64742 Transection or avulsion of; facial nerve, differential or complete 64864 Suture of facial nerve; extracranial 64865 Suture of facial nerve; infratemporal, with or without grafting 64866 Anastomosis; facial-spinal accessory Rev 12/30/15 Page 28 of 50

64868 Anastomosis; facial-hypoglossal 64870 Anastomosis; facial-phrenic 66174 Canaloplasty - Transluminal dilation of aqueous outflow canal; without retention of device or stent 66175 Canaloplasty - Transluminal dilation of aqueous outflow canal; with retention of device or stent 66183 Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach 67220 Treatment of choroid lesion 67299 Suprachoroidal delivery of pharmacologic agent (does not include supply of medication) 67345 Chemodenervation of extraocular muscle 67900 Blepharoplasty - repair of brow ptosis ( supraciliary, mid-forehead or cornal approach) 67901 Blepharoplasty - repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) 67902 Blepharoplasty - repair of blepharoptosis; frontalis muscle technique with autolgous facial sling (includes obtaining fascia) 67903 Blepharoplasty - repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 67904 Blepharoplasty - repair of blepharoptosis; (tarso) levator resection or advancement, external approach 67906 Blepharoplasty - repair of blepharoptosis; superior rectus technique with facial sling (includes obtaining fascia) 67908 Blepharoplasty - repair of blepharoptosis; conjunctivo-tarso-muller's muscle-levator resection (eg, Fasanella-Servat type) 69090 Ear piercing 69300 Otoplasty, protruding ear, with or without size reduction 69710 Implant/replace hearing aid 69714 Implantable hearing aids 69715 Implantation, osseointegrated implant, temporal bone 69717 Bone-Anchored Hearing Aids -Replacement (including removal of existing device), osseointegrated implant, temporal bone Rev 12/30/15 Page 29 of 50

69718 Bone-Anchored Hearing Aids - Replacement (including removal of existing device), osseointegrated implant, temporal bone 69930 Cochlear device implantation, with or without mastoidectomy 69955 Total facial nerve decompression and/or repair (may include graft) 74261 Virtual Colonoscopy - Computed tomographic (CT) colonography, diagnostic, including image post processing; without contrast material 74262 Virtual Colonoscopy - Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material(s) including non-contrast images, if performed 74263 Virtual Colonoscopy - Computed tomographic (CT) colonography, screening, including image post processing 75571 Ultra-fast CT - Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound or other tomographic modality; not requiring image post processing on an independent workstation. 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound or other tomographic modality; requiring image post processing on an independent workstation. 76390 Magnetic Resonance Spectroscopy 76499 Unlisted Diagnostic Radiographic Procedure 77058 MRI - Breast 77059 MRI - Breast 77301 IMRT - Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications 77338 IMRT - Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan 77385 IMRT - Intensity modulated radiation treatment delivery, includes guidance and tracking, when performed; simple Rev 12/30/15 Page 30 of 50

77386 IMRT - Intensity modulated radiation treatment delivery, includes guidance and tracking, when performed; complex 77520 Proton Beam Therapy 77522 Proton Beam Therapy 77523 Proton Beam Therapy 77525 Proton Beam Therapy 81211 Genetic testing for cancer susceptibility - BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 81212 Genetic testing for cancer susceptibility - BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis 81213 Genetic testing for cancer susceptibility - BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants 81214 Genetic testing for cancer susceptibility - BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants 81215 Genetic testing for cancer susceptibility - BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant 81216 Genetic testing for cancer susceptibility - BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis 81217 Genetic testing for cancer susceptibility - BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant 81276 Genetic Testing for Inherited Peripheral Neuropathies - Molecular pathology procedure, Level 4 Rev 12/30/15 Page 31 of 50

81292 Genetic testing for cancer susceptibility - MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81293 Genetic testing for cancer susceptibility - MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81294 Genetic testing for cancer susceptibility - MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 81295 Genetic testing for cancer susceptibility - MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81296 Genetic testing for cancer susceptibility - MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81297 Genetic testing for cancer susceptibility - MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 81298 Genetic testing for cancer susceptibility - MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81299 Genetic testing for cancer susceptibility - MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81300 Genetic testing for cancer susceptibility - MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81317 Genetic testing for cancer susceptibility - PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81318 Genetic testing for cancer susceptibility - PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81319 Genetic testing for cancer susceptibility - PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 81321 Genetic Testing for PTEN Hamartoma Tumor Syndrome - PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, Rev 12/30/15 Page 32 of 50

PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis 81322 Genetic Testing for PTEN Hamartoma Tumor Syndrome - PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant 81323 Genetic Testing for PTEN Hamartoma Tumor Syndrome - PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant] 81324 Genetic Testing for Inherited Peripheral Neuropathies - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis 81325 Genetic Testing for Inherited Peripheral Neuropathies - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis 81326 Genetic Testing for Inherited Peripheral Neuropathies - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant 81402 Genetic Testing for Inherited Peripheral Neuropathies - Molecular pathology procedure, Level 3 81404 Genetic Testing for Inherited Peripheral Neuropathies - Molecular pathology procedure, Level 5 81405 Genetic Testing for Inherited Peripheral Neuropathies - Molecular pathology procedure, Level 6 81406 Genetic Testing for Inherited Peripheral Neuropathies - Molecular pathology procedure, Level 7 81479 Unlisted molecular pathology procedure 81519 Oncology (breast), mrna, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score 81599 Unlisted multianalyte assay with algorithmic analysis [when specified as testing for thyroid molecular markers] 84112 AmniSure ROM (Rupture of Membranes) Test 89344 Cryopreservation of Oocytes or Ovarian Tissue - Storage, (per year); reproductive tissue, testicular/ovarian [specified as ovarian tissue] Rev 12/30/15 Page 33 of 50

89354 Cryopreservation of Oocytes or Ovarian Tissue - Thawing of cryopreserved; reproductive tissue, testicular/ovarian [specified as ovarian tissue] 91110 Capsule Endoscopy - Gastrointestinal tract imaging, intraluminal, esophagus through ileum, with physician interpretation and report 91111 Capsule Endoscopy - Gastrointestinal tract imaging, intraluminal, esophagus, with physician interpretation and report 93228 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report 93229 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports 93580 Transcatheter closure of a patent foramen ovale - Percutaneous transcatheter closure of congenital interatrial communication (i.e., fontan fenestration, atrial septal defect) with implant 95803 Sleep study/actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) 95965 Magnetoencephalography (MEG) 95966 Magnetoencephalography (MEG) 95967 Magnetoencephalography (MEG) 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session 0019T 0054T 0055T 0071T Extracorpeal shock wave therapy (Orthotripsy)/Orthotripsy (heel) Ossatron Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images Focused ultrasound ablation of uterine leiomyomata Rev 12/30/15 Page 34 of 50

0072T 0075T 0076T 0095T 0098T 0101T 0102T 0163T 0164T 0165T 0171T 0172T 0191T 0195T 0196T 0200T Focused ultrasound ablation of uterine leiomyomata Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s); initial vessel Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s); each additional vessel Artificial Intervertebral Discs - Removal of total disc arthroplasty, anterior approach cervical; each additional interspace Artificial Intervertebral Discs - Revision of total disc anthroplasty, anterior approach cervical; each additional interspace Extracorpeal shock wave therapy (Orthotripsy) Extracorpeal shock wave therapy (Orthotripsy) Artificial Intervertebral Discs - total disc arthroplasty, anterior approach, including diskectomy to prepare interspace (other than for decompression); lumbar, each additional interspace Artificial Intervertebral Discs - Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace Artificial Intervertebral Discs - Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace Insertion of posterior spinous process distraction device, lumbar; single level Insertion of posterior spinous process distraction device, lumbar; each additional level Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach Spinal fusion - Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; single interspace Spinal fusion - Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; each additional interspace (List separately in addition to code for primary procedure) Kyphoplasty - Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed Rev 12/30/15 Page 35 of 50

0201T 0202T 0219T 0220T 0221T 0222T 0282T 0283T 0284T 0285T 0309T 0331T 0332T Kyphoplasty - Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed Implanted Devices for Spinal Stenosis - Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed Spinal Fusion - Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace Myocardial sympathetic innervation imaging, planar qualitative and quantitative Y assessment Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT Rev 12/30/15 Page 36 of 50

0335T 0340T 0342T 0375T 0376T A0380 A0390 A0425 A0426 A0428 A0430 A0431 A0435 A0436 A0999 A7025 A9274 A9582 C1300 Subtalar Joint Implantation - Extra-osseous subtalar joint implant for talotarsal stabilization Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance Therapeutic apheresis with selective HDL delipidation and plasma reinfusion Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork; each additional device insertion BLS mileage (per mile) non-emergency transport ALS mileage (per mile) non-emergency transport Ground ambulance mileage, per statute mile non-emergency transport Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1) Ambulance service, basic life support, non-emergency transport (BLS) Ambulance service, conventional air services, non-emergency transport, one way (fixed wing) Ambulance service, conventional air services, non-emergency transport, one way (rotary wing) Ambulance service - Fixed wing air mileage, per statute mile - non-emergency transport Ambulance service - Rotary wing air mileage, per statute mile - non-emergency transport Ambulance service - Unlisted [when specified as ambulance service, water transport] - non-emergency transport High frequency chest wall oscillation system vest, replacement for use with patient owned equipment External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories Myocardial sympathetic innervations imaging with or without SPECT - Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries [AdreView; when specified for use in myocardial imaging] Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval Rev 12/30/15 Page 37 of 50

C1721 C1722 C1777 C1882 C1895 C1896 C8903 C8904 C8905 C8906 C8908 C9727 D7810 D7820 D7830 D7840 D7850 D7852 D7854 D7856 D7858 D7860 Cardioverter-defibrillator, dual chamber (implantable) Cardioverter-defibrillator, single chamber (implantable) Cardiac Resynchronization Therapy - Lead, cardioverter-defibrillator, endocardial single coil (implantable) Cardioverter-defibrillator, other than single or dual chamber (implantable) Cardiac Resynchronization Therapy - Lead, cardioverter-defibrillator, endocardial dual coil (implantable) Cardiac Resynchronization Therapy - Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable) MRI - Breast MRI - Breast MRI - Breast MRI - Breast MRI - Breast Insertion of implants into the soft palate; minimum of three implants Temporomandibular Disorders: Open reduction of dislocation Temporomandibular Disorders: Closed reduction of dislocation Temporomandibular Disorders: Manipulation under anesthesia Temporomandibular Disorders: Condylectomy Temporomandibular Disorders: Surgical discectomy with/without implant-excision of the intra-articular disc of a joint Temporomandibular Disorders: Disc repair Temporomandibular Disorders: Synovectomy Temporomandibular Disorders: Myotomy Temporomandibular Disorders: Joint reconstruction Temporomandibular Disorders: Arthrotomy Rev 12/30/15 Page 38 of 50

D7865 D7870 D7871 D7873 D7874 D7875 D7876 D7877 D7880 D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7995 Temporomandibular Disorders: Arthroplasty Temporomandibular Disorders: Arthrocentesis Temporomandibular Disorders: Nonarthroscopic lysis and lavage Temporomandibular Disorders: Arthroscopy-surgical: lavage and lysis of adhesions Temporomandibular Disorders: Arthroscopy - surgical: debridement Temporomandibular Disorders: Arthroscopy - surgical: synovectomy Temporomandibular Disorders: Arthroscopy - surgical: discectomy Temporomandibular Disorders: Arthroscopy - surgical: debridement Temporomandibular Disorders: Occlusal orthotic appliance Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty - for orthognathic deformities Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy; mandibular rami Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy; mandibular rami with bone graft; includes obtaining the graft Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy-segmented or subapical-per sextant or quadrant Mandibular/Maxillary (Orthognathic) Surgery -Osteotomy-body of mandible Mandibular/Maxillary (Orthognathic) Surgery - LeFort I (maxilla, total) Mandibular/Maxillary (Orthognathic) Surgery - LeFort I (maxilla - segmented) Mandibular/Maxillary (Orthognathic) Surgery - LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion); without bone graft Mandibular/Maxillary (Orthognathic) Surgery - LeFort II or LeFort III; with bone graft Mandibular/Maxillary (Orthognathic) Surgery - Osseous graft to mandible Mandibular/Maxillary (Orthognathic) Surgery - Synthetic graft, mandible or facial bones, by report Rev 12/30/15 Page 39 of 50

D7996 D9940 D9950 D9951 D9952 E0217 E0218 E0236 E0481 E0483 E0638 E0641 E0642 E0652 E0656 E0657 E0670 E0671 E0672 E0673 Mandibular/Maxillary (Orthognathic) Surgery - Implant-mandible or augmentation purposes (excluding alveolar ridge) Temporomandibular Disorders: Occlusal guard, by report Temporomandibular Disorders: Occlusion analysis- mounted case Temporomandibular Disorders: Occlusal adjustment- limited Temporomandibular Disorders: Occlusal adjustment- complete Cooling Devices and Combined Cooling/Heating Devices - Water circulating heat pad with pump [when specified as a cooling/heating combination device] Cooling Devices and Combined Cooling/Heating Devices - Water circulating cold pad with pump Cooling Devices and Combined Cooling/Heating Devices - Pump for water circulating pad Intrapulmonary percussive ventilation system and related accessories High frequency chest wall oscillation air-pulse generator system, includes hoses and vest Standing frame system, one position (e.g. upright, Standing frame system, multi-position (e.g. three- Standing frame system, mobile (dynamic stander), any size including pediatric Pneumatic Compression Devices for Lymphedema - segmental home model with calibrated gradient pressure Pneumatic Compression Devices for Lymphedema - Segmental pneumatic appliance for use with pneumatic compressor, trunk Pneumatic Compression Devices for Lymphedema -Segmental pneumatic appliance for use with pneumatic compressor, full leg Pneumatic Compression Devices for Lymphedema - Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk Pneumatic Compression Devices for Lymphedema - Segmental gradient pressure pneumatic appliance, full leg Pneumatic Compression Devices for Lymphedema - Segmental gradient pressure pneumatic appliance, full arm Pneumatic Compression Devices for Lymphedema - Segmental gradient pressure pneumatic appliance, half leg Rev 12/30/15 Page 40 of 50

E0745 E0747 E0748 E0749 E0760 E0764 E0770 E0784 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1009 E1010 E1012 E1230 Neuromuscular stimulator, electronic shock unit Bone Growth Stimulators - Osteogenesis stimulator; electrical, noninvasive, other than spinal applications Bone Growth Stimulators - Osteogenesis stimulator; electrical, noninvasive, spinal applications Bone Growth Stimulator - electrical surgically implanted Bone Growth Stimulators - Low intensity ultrasound stimulation to aid bone healing, noninvasive (non-operative) Functional neuromuscular stimulator, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified Insulin Pump Wheelchair accessory, power seating system Wheelchair accessory, power seating system Wheelchair accessory, power seating system Wheelchair accessory, power seating system Wheelchair accessory, power seating system Wheelchair accessory, power seating system Wheelchair accessory, power seating system Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system including pushrod and leg rest, each Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair Wheelchair accessory, power seating system Wheelchair - Power operated vehicle (three- or four-wheel non highway) Rev 12/30/15 Page 41 of 50

E1239 E1399 E1902 E2120 E2300 E2301 E2351 E2500 Wheelchair - Power wheelchair, pediatric size, not otherwise specified Misc/Unlisted DME code Speech Generating Devices - Communication board, non-electronic augmentative or alternative communication device Pulse generator system for tympanic treatment of inner ear endolymphatic fluid Power wheelchair accessory, power seat elevation system Power wheelchair accessory, power standing system Power wheelchair accessory, electronic interface to operate speech generating device using Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time E2502 Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time E2504 Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time E2506 Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time E2508 E2510 G6015 G6016 J0180 J0220 Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access IMRT - Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session IMRT - Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session Agalsidase beta (Fabrazyme) Alglucosidase alfa, 10 MG (Myozyme, Lumizyme) Rev 12/30/15 Page 42 of 50

J0221 J0598 J1300 J1786 J3385 J7178 J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7198 Alglucosidase alfa, 10 MG (Lumizyme) C-1 esterase inhibitor (human), 10 units (Cinryze) Eculizumab (Soliris) Imiglucerase (Cerezyme) Velaglucerase alfa (VPRIV) Fibrinogen Concentrate (RiaSTAP) Factor XIII (Corifact) Factor XIII (Tretten) Factor VIII (Novoeight) Factor VIII (Wilate) Factor VIII (Xyntha) Factor VIII (Alphanate) Factor VIII (Humate-P) Factor VIIa (Novoseven) Factor VIII (Doate DVI, Hemofil M, Monoclate-P) Factor VIII (Obizur) Factor VIII (Advate, Helixate-FS, Kogenate-FS, Recombinate) Factor IX (AlphaNine SD, Mononine) Factor IX (Bebulin VH, Profilnine SD) Factor IX (Benefix) Anti-inhibitor Coagulant Complex (Feiba) Rev 12/30/15 Page 43 of 50

J7199 Hemophilia clotting factor (Eloctate) J7200 Factor IX (Rixubis) J7201 Recombinant Coagulation Factor IX, Fc Fusion Protein (rfixfc), (Alprolix) J7330 Autologous cultured chondrocytes knee, implant K0005 Wheelchair - Ultra lightweight K0010 Wheelchair - Motorized/power K0011 Wheelchair - Motorized/power K0012 Wheelchair - Motorized/power K0013 Wheelchair - Motorized/power K0014 Wheelchair - Motorized/power K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type K0800 Wheelchair - Power operated vehicle, group 1 K0801 Wheelchair - Power operated vehicle, group 1 K0802 Wheelchair - Power operated vehicle, group 1 K0806 Wheelchair - Power operated vehicle, group 2 K0807 Wheelchair - Power operated vehicle, group 2 K0808 Wheelchair - Power operated vehicle, group 2 K0812 Wheelchair - Power operated vehicle, not otherwise classified [scooter] K0813 Wheelchair - Power wheelchair, group 1 standard K0814 Wheelchair - Power wheelchair, group 1 standard K0815 Wheelchair - Power wheelchair, group 1 standard Rev 12/30/15 Page 44 of 50

K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 Wheelchair - Power wheelchair, group 1 standard Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 2 standard/heavy duty Rev 12/30/15 Page 45 of 50

K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 Wheelchair - Power wheelchair, group 2 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 3 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Rev 12/30/15 Page 46 of 50

K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0899 L5856 L5857 L5858 L5859 L6025 L6611 Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 4 standard/heavy duty Wheelchair - Power wheelchair, group 5 pediatric Wheelchair - Power wheelchair, group 5 pediatric Wheelchair - Power wheelchair, not otherwise classified Wheelchair - Power mobility device, not coded by DME PDAC or does not meet criteria Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) Custom prosthesis - Partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device Custom prosthesis - Addition to upper extremity prosthesis, external powered, additional switch, any type Rev 12/30/15 Page 47 of 50

L6677 L6881 L6925 L6935 L6945 L6955 L6965 L6975 L7007 L7008 L7009 L7045 L7180 L7181 L7190 L7191 L8614 L8619 L8627 Custom prosthesis - Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow Custom Prosthesis - Automatic grasp feature, addition to upper limb prosthetic terminal device Custom prosthesis - Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell Custom prosthesis - Below elbow, external power, self-suspended inner socket, removable forearm shell Custom prosthesis - Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Custom prosthesis - Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm Custom prosthesis - Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm Custom prosthesis - Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm Custom Prosthesis - Adult electric hand Custom prosthesis - Electric hand, switch or myoelectric controlled, pediatric Custom prosthesis - Electric hook, switch or myoelectric controlled, adult Custom prosthesis - Electronic hook, child, Michigan or equal, switch controlled Custom prosthesis - Electronic elbow, Boston, Utah or equal, myoelectronically controlled Custom prosthesis - Electronic elbow, microprocessor simultaneous control of elbow and terminal device Custom prosthesis - Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled Custom prosthesis - Electronic elbow, child, variety village or equal, myoelectronically controlled Cochlear device, includes all internal and external components Cochlear Implant - external speech processor and controller, integrated system, replacement Cochlear Implant - external speech processor, component, replacement Rev 12/30/15 Page 48 of 50

L8628 L8680 L8682 L8683 L8684 L8685 L8686 L8687 L8688 L8690 L8691 L8699 S2066 S2067 S2068 S2080 S2112 S2117 Cochlear Implant - external controller component, replacement Neurostimulator Implantation Implantable Neurostimulator Electrode Neurostimulator Implantation - Implantable Neurostimulator Radiofrequency Receiver Neurostimulator Implantation - Radiofrequency Transmitter (external) For Use With Implantable Neurostimulator Radiofrequency Receiver Neurostimulator Implantation - Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, single array, rechargeable, includes extension Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, single array, non-rechargeable, includes extension Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, dual array, rechargeable, includes extension Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, dual array, non-rechargeable, includes extension Bone-Anchored Hearing Aids - Auditory osseointegrated device, includes all internal and external components Cochlear Implant - Auditory osseointegrated device, external sound processor, replacement Prosthetic implant, not otherwise specified [when describing replacement components of an auditory brain stem implant] Breast procedure - Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral Breast procedure - Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator Breast procedure - Breast reconstruction with deep inferior epigastric perforator flap or superficial inferior epigastric artery flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral Laser-assisted uvulopalatoplasty Autologous chondrocyte transplantation/arthroscopy knee, surgical harvesting of cartilage (chondrocyte cells) Subtalar Arthroereisis - Arthroereisis, subtalar Rev 12/30/15 Page 49 of 50

S2120 S2202 S2230 S2235 S2300 S2342 S2350 S2351 S2360 S2361 S8030 S8092 Unlisted codes V2788 Therapeutic Apheresis - Low density lipoprotein (LDL) apheresis using heparin-induced extracorporeal LDL precipitation Sclerotherapy Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear Cochlear Implant - implantation of auditory brain stem implant Electrothermal capsular shrinkage - Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, each additional interspace Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; cervical Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional cervical (list separately in addition to primary procedure) Proton Beam Therapy Ultra-fast CT - Electron beam computed tomography Unlisted CPT codes Presbyopia correcting function of intraocular lens Rev 12/30/15 Page 50 of 50